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Face Value of Life Insurance

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					                                                                                                               Personal Financial Statement
                                                                                                               Complete Page 2 First




Name                                                                                                                      S.S. Number
                                       (One Name if Statement for One Individual Only)

Name                                                                                                                      S.S. Number
                                             (Second Name if Statement is Joint)

Home Address                                                                                                                 Telephone
Business Address                                                                                                             Telephone
Position or Occupation                                                                                                     Accountant

                    STATEMENT OF CONDITION AS OF                                               November 14, 2010
                   ASSETS                                              DOLLARS                             LIABILITIES                              DOLLARS
Cash                                                      A                              -   Accounts & Bills Due
Cash Value Life Insurance                                 B                              -   Cash Value Insurance Loans                        B                        -
Listed Securities                                         C                              -   Secured Debt Due Others                           H                        -
Unlisted Securities                                       D                              -   Unsecured Debt Due Others                         H                        -
Accounts/Notes Receivable                                 E                              -   Accrued Taxes
Real Estate - Owned                                       F                              -   Real Estate Mortgages                             F                        -
Real Estate - Partial Interest                            G                              -   Real Estate - Partial Interest                    G                        -
Automobiles                                                                                  Other Debts - Itemize
Personal Property
Other Assets - Itemize



                                                                   Total Liabilities                                                                                    -
                                                                   Net Worth                                                                                            -
Total Assets                                 $             - Total Liabilities & Net Worth             $                                                                -
                             INCOME SOURCE                                      PERSONAL INFORMATION
Salary                                                       Date of Birth
Bonus/Commissions                                            Do You Have a Will ?                 Executor:
Dividends/Interest                                           Have you been declared bankrupt in the last 14 yrs?
Real Estate Income                                           Explain:
                                                             Are you a defendant in legal action?
               Total                         $             - Explain:
                                CONTINGENT LIABILITIES AS COMAKER, ENDORSER, GUARANTOR
Debt Payable By                                              Debt Payable To                                                                              Amount Due




                                               (BOTH SIDES OF THIS STATEMENT MUST BE COMPLETE)
For the purpose of procuring and maintaining credit, I/we submit the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby
given to First National Bank of Fort Smith to verify in any manner it deems appropriate items indicated on this statement. The undersigned also agrees to notify the Lender
immediately in writing of any significant changes in such financial condition.

The Undersigned certifies that the information provided on both sides of this statement is true and correct.
PLEASE READ CAREFULLY
IN CONSIDERING THIS LOAN REQUEST FROM YOU, THE BANK WILL RELY HEAVILY ON THE INFORMATION YOU HAVE SUPPLIED. IT IS MOST IMPORTANT THAT THE INFORMATION BE
ACCURATE AND COMPLETE. BY SIGNING THIS APPLICATION, YOU REPRESENT AND WARRANT THE ACCURACY OF THE INFORMATION. THIS APPLICATION SHALL REMAIN THE PROPERTY
OF THE BANK WHETHER THE ACCOUNT IS GRANTED OR NOT. BY SIGNING BELOW I AUTHORIZE YOU TO CHECK MY CREDIT AND EMPLOYMENT HISTORY AND TO ANSWER ANY
QUESTIONS OTHERS MAY ASK YOU ABOUT MY CREDIT RECORD WITH YOU.



FEDERAL CREDIT APPLICATION INSURANCE DISCLOSURE
I HAVE APPLIED FOR AN EXTENSION OF CREDIT WITH YOU. YOU ARE SOLICITING, OFFERING, OR SELLING ME AN INSURANCE PRODUCT OR ANNUITY IN CONNECTION WITH THIS
EXTENSION OF CREDIT. FEDERAL LAW PROHIBITS YOU FROM CONDITIONING THE EXTENSION OF CREDIT ON EITHER:

1. MY PURCHASE OF AN INSURANCE PRODUCT OR ANNUITY FROM YOU OR FROM ANY OF YOU AFFILIATES; OR

2. MY AGREEMENT NOT TO OBTAIN, OR A PROHIBITION ON ME FROM OBTAINING, AN INSURANCE PRODUCT OR ANNUITY FROM AN UNAFFILIATED ENTITY.

BY SIGNING, I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS FORM ON TODAY’S DATE. UNLESS THIS DISCLOSURE IS PROVIDED ELECTRONICALLY OR I HAVE APPLIED FOR CREDIT BY MAIL, I A



ARKANSAS CREDIT APPLICATION INSURANCE DISCLOSURE
I HAVE APPLIED FOR AN EXTENSION OF CREDIT FROM YOU. YOU ARE OFFERING, SELLING, OR REQUIRING INSURANCE AS A PART OF THE EXTENSION OF CREDIT. YOUR CHOICE OF AN
INSURER OR PRODUCER SHALL NOT AFFECT OUR CREDIT DECISION OR CREDIT TERMS IN ANY WAY. HOWEVER, WE MAY IMPOSE REASONABLE REQUIREMENTS CONCERNING THE
CREDITWORTHINESS OF THE INSURER AND THE SCOPE OF THE COVERAGE CHOSEN. BY SIGNING, I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS DISCLOSURE ON TODAY’S
DATE.




                           Date                                                                                          (Signature)



                                                                                                            (Second Signature if Joint Statement)



                                                NOTE: Any willful misrepresentation could result in violation of Federal Law
                                                                   (BOTH SIDES OF THIS STATEMENT MUST BE COMPLETE)
                                                                      CASH - DEPOSITORY RELATIONSHIPS
SCHEDULE A


                         Type Account                                                                      Where Deposited                     Amount
                                                                                                                                                        -
                                                                                                                                                        -
                                                                                                                                                        -
                                                                                                                                                        -
                                                             LIFE INSURANCE - FACE VALUE & CASH VALUE
SCHEDULE B




                            Face Value                              Name of Company               Beneficiary                    Cash Value     Loans
                                                                                                                                          -             -



                                                                    LISTED SECURITIES - ACTIVELY TRADED
                        Number of       Market Value
SCHEDULE C




                                                                                  Description of Securities                            In Name of
                         Shares       Each    Total
                                                        -



                                                        -
                                                        -
                                               UNLISTED SECURITIES - NOT ACTIVELY TRADED - Closely Held
SCHEDULE E SCHEDULE D




                        Number of      Book Value    To
                                                                               Description of Securities
                         Shares     Each     Total   tal
                                                   -
                                                   -
                                                   -
                                                          ACCOUNTS & NOTES RECEIVABLE
                                Debt Payable By                        Repayment Terms                   Amount                               Doubtful ?
                                                                                                                                         -


                                                                              REAL ESTATE OWNED
SCHEDULE F




                         Description of                                                                                               Mortgage
                                            Title in Name of          Date Acquired         Cost              Market Value
                           Property                                                                                               Amount    Maturity
                                                                                                                             -           -
                                                                                                                                         -
                                                                                                                                         -
                                                                                                                                         -
                                                                      PARTIAL INTEREST IN REAL ESTATE
SCHEDULE G




                         Description of                      Or                         Mortgage     Your % Your Equity
                                            Year Purchased           Market Value Today            Equity Value
                           Property                          igi                         Owing      Ownership  Value
                                                                                                 --                    -
                                                                                                  -                    -
                                                                                                  -                    -
                                          DEBTS DUE BANKS, SAVINGS & LOANS, FINANCE COMPANIES, AND OTHERS
                                                                                                     Current  Original
                                         Name of Lender                Repayment Terms
                                                                                                      Owing   Owing
SCHEDULE H


                          Secured
                          Unsecured
                                                         (BOTH SIDES OF THIS STATEMENT MUST BE COMPLETE)
                                                                 CASH - DEPOSITORY RELATIONSHIPS
SCHEDULE A                          Type Account                                                  Where Deposited                        Amount




                                                             LIFE INSURANCE - FACE VALUE & CASH VALUE
SCHEDULE B




                                     Face Value                     Name of Company           Beneficiary                  Cash Value     Loans




                                                                     LISTED SECURITIES - ACTIVELY TRADED
                        Number of                Market Value
SCHEDULE C




                                                                                Description of Securities                        In Name of
                         Shares                Each      Total
                                                                 -
                                                                 -
                                                                 -
                                                                 -
                                                                 -
                                                     UNLISTED SECURITIES - NOT ACTIVELY TRADED - Closely Held
SCHEDULE E SCHEDULE D




                        Number of                 Book Value      Total Shares
                                                                                           Description of Securities
                         Shares                Each     Total     Outstanding
                                                                -
                                                                -
                                                                -
                                                                   ACCOUNTS & NOTES RECEIVABLE
                                                Debt Payable By                  Repayment Terms               Amount                   Doubtful ?



                                                                            REAL ESTATE OWNED
SCHEDULE F




                                    Description of                                Date                                           Mortgage
                                                           Title in Name of               Cost              Market Value
                                      Property                                  Acquired                                    Amount      Maturity




                                                                    PARTIAL INTEREST IN REAL ESTATE
SCHEDULE G




                                    Description of   Year Purchased Original Cost
                                                                                  Market Value Mortgage                 Your %   Your Equity
                                                                                     Today
                                                                                                          Equity Value
                                      Property                                                   Owing                 Ownership   Value
                                                                                                                     -                     -
                                                                                                                     -                     -
                                                                                                                     -                     -
                                              DEBTS DUE BANKS, SAVINGS & LOANS, FINANCE COMPANIES, AND OTHERS
                                                                                                                        Current   Original
                                                   Name of Lender                            Repayment Terms
                                                                                                                        Owing      Owing
SCHEDULE H
                        Secured
                        Unsecured

				
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